Search for tag: "cpr"

Dr. Gellner: If you've ever seen a child choke, not just gag, but truly chokem then you will probably go into panic mode just like the choking child. But keeping calm can help you do the right thing. I'll discuss what to do for a choking child on today's Scope. I'm Dr. Cindy Gellner.

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Dr. Gellner: First, if the child is breathing and coughing, encourage them to cough hard. Don't give them anything to drink because the fluid might take up space needed for the passage of air and completely block off their airway. Next, give the child first-aid. It's a good thing for all parents to take a CPR class, because they'll also teach the Heimlich maneuver in those classes as well. Also, have someone call 911 in case the object stays lodged, and the child stops breathing.

For children over a year old, you want to give them high abdominal thrusts. Grab the child from behind, and put your hands just below the lower ribs, but above their belly button, like you were giving them a big bear hug. Make a fist with one hand, and fold the other over it, and then give sudden upward and backward jerks with your fist to try to squeeze all the air out of the chest and pop the object out of their airway.

For babies under a year old, you don't want to do that technique, because you could rupture their spleens or livers. You'll want to put the baby face down at a 60 degree incline over your knees, and with their head down. Then give five quick blows with the heel of your hand between their shoulder blades. If they're still choking and not breathing, lay them on the floor, and give them five rapid chest compressions over the lower third of the breastbone using only two fingers. Alternate the back blows and chest thrusts until EMS gets there.

Remember, never be afraid to call 911 as soon as the child chokes.

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Interviewer: It's a new technique that some emergency rooms are using to save lives. Learn about eCPR. That's next on The Scope.

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Interviewer: So you've heard of CPR, what happens when you throw an E in front of it and you get eCPR? Well, it's a new technique that we're going to learn a little bit more about from an emergency room physician, Dr. Scott Youngquist. What is eCPR? What does that stand for?

Dr. Youngquist: eCPR stands for extracorporeal cardio pulmonary resuscitation, and the idea is that instead of pressing on the chest rhythmically to circulate blood, you actually withdraw blood from the patient and using a mechanical pump, pump it back into the patient, fully oxygenated and under pressure.

Interviewer: All right. What was this born out of?

Dr. Youngquist: Well, this goes back decades to really the 1930s with the development of heart-lung bypass. This heart-lung bypass was used in the operating room to allow cardio-thoracic surgeons to perform blue baby operations and to perform coronary bypass. So it's been used there extensively and has been very expensive.

Interviewer: All right. And now, it's being used in the emergency room. It's kind of old technology, new application. Why is it coming to emergency rooms?

Dr. Youngquist: Well, for several reasons. One is that the cardiac arrest survival rates have not moved much in the last 30 years. So we've kind of reached the pinnacle of resuscitation using closed chest compressions and defibrillation. And unfortunately, we only get about seven and a half percent of patients out of the hospital neurologically intact and whom we attempt usual care, namely, chest compressions and defibrillation.

Interviewer: Yeah. So you're looking to up that percentage a little bit.

Dr. Youngquist: Absolutely. So one of the rationales for using this external pump is that it provides much better blood flow than just pressing on the chest.

Interviewer: And how is it doing? Is it doing better than 7%?

Dr. Youngquist: It's doing better than 7%. Several centers are reporting that in carefully selected patients, 50% of these victims are surviving once they're placed on pump and recall that these are patients in whom the standard measures have already failed.

Interviewer: Right. Because this is somebody who's had a cardiac arrest in the field, they've been put on an ambulance, the compression is probably all the way to the hospital, then they get put on more compressions at the hospital before the machine comes on? I mean how does that process even work?

Dr. Youngquist: Yeah, absolutely. So the resuscitation has to go seamlessly from the field where bystanders hopefully start chest compressions till when EMS arrives. They continue chest compressions and defibrillation attempts, identify the patient as suitable for ECMO possibly and move them to the emergency department. And then the ED, in the emergency department, we continue compressions while we try to get access for placing the patient on pump. So usually, it takes somewhere between 45 and 60 minutes at best to get the person on the pump.

Interviewer: So why aren't we putting the pumps in the ambulances for the first responders?

Dr. Youngquist: Well, that's a good question. It's a highly tactical skill, so right now it requires a physician to place the patient on the pump. And some places are actually doing this, places like Paris, France, where physicians ride on ambulances and take this machine to the field where they can insert catheters and place the patient on pump, in places like the Louvre even or a supermarket.

Interviewer: Yeah, and what are their percentages? Is it much better than the way it's currently here in the United States?

Dr. Youngquist: Well, it's too early to tell. They haven't reported fully on their outcomes, but this is an ongoing trial in Europe.

Interviewer: And the difference is there are doctors on those ambulances that can actually do that. Here in the United States, we don't have that. So when you get back to the emergency room, it's not the emergency room personnel that are actually hooking people up, it's cardiologists.

Dr. Youngquist: Well, it depends. At our institutions, it's cardiothoracic surgeons. In some locations, it's cardiologists working with the emergency physicians, and in some locations it's actually emergency physicians doing the whole thing, putting them on the pump and then admitting them to the ICU.

Interviewer: And you said people have to be screened whether or not they're going to be even eligible at this point. So they make it back to the emergency department, then there's additional criteria to determine if this pump can be used. What are those?

Dr. Youngquist: Well, we're not sure exactly which patients will benefit the most, but we have some good idea. We think it's patients that initially have a shockable rhythm and don't have a lot of comorbidities. So people who already have advanced cancer or heart failure, cirrhosis of the liver, renal failure, those patients aren't likely to benefit from this life extending care which is really heroic.

Interviewer: Yeah. So another good reason to try to stay as healthy as possible I suppose where you can.

Dr. Youngquist: Absolutely.

Interviewer: What's the future of this technology from what you're seeing right now?

Dr. Youngquist: Well, we're seeing a year-by-year expansion in use and availability of eCPR to cardiac arrest victims in the United States and elsewhere. There is a large registry called ELSO which tracks this and this has been going up exponentially each year. And part of that tracks with the scale and cost of the equipment coming down over time.

Interviewer: And then at the end of the day, you mentioned 50%, like is it a 50% increase?

Dr. Youngquist: It's about 50% of patients who go on the pump who survive, and this is a case series that's selected from patients who have already failed at least 60 minutes of usual care. In those cases, continuing CPR may result in a few survivors but it's usually less than 5%.

Interviewer: Okay. So is there a point where you have to look at the expense, the necessary equipment versus the survival rate? Is 50% a pretty good number to offset the balance of the other aspects of providing this care?

Dr. Youngquist: Yeah. I would say that's a great number considering the overall survival at that time period is less than 5%. So we've given the person a tenfold increase in survival by providing this therapy.

Interviewer: All right. And we have this technology here at University of Utah Health?

Dr. Youngquist: Yes, we do. For a couple of years, we've been providing this therapy to select patients who meet our criteria.

Interviewer: But there are some places still without it but hopefully, someday soon.

Dr. Youngquist: Yes.

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Scot: Somebody's choking on some food, what do you do? Do you give the Heimlich maneuver? Do you even know how? We're going to find out the answers to those and other questions right now, with Dr. Troy Madsen, Emergency of Medicine at University of Utah Hospital.

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Scot: Let's talk about the Heimlich maneuver. Is an effective tool.

Dr. Madsen: It is. You know, the Heimlich maneuver actually works, and we talk about CPR sometimes, and we talk about well maybe CPR works, maybe 5 to 10% of the time. The Heimlich maneuver, in my experience, works most of the time. And it's really surprising to me, because we think about all this research we have on CPR. I just can't find much research at all on the Heimlich maneuver. But I can tell you, I've seen many cases in the E.R. of people who have been brought in, who are say at a restaurant or at home, something happened. Someone administered the Heimlich maneuver, it got that piece of meat or food out, and they came in the E.R. and were fine. You know, they walked out of the E.R. later. So there's no question in my mind it works and it works the majority of the time.

Scot: So there are likely all sorts of videos online, if you want to learn how to do the Heimlich maneuver.

Dr. Madsen: Sure.

Scot: Can you do a brief overview of what you should do? And then I'd like to find out from your perspective, how do I know I'm doing it right?

Dr. Madsen: Yeah. Yes, so the big thing you want to do is number one, stand behind the person. So as long as you can get behind them, that's a great position to be in. And then reach around the front, make one hand into a fist, the other hand on top of it. Place that fist just down below the rib cage in the midline, so you're right over the stomach there, and then with both hands force that stomach up. And so if you really think about what you're doing, like I said, you're thinking you're forcing the stomach. The big thing I'm trying to do is just put lots of pressure on the lungs, because we've got food stuck in the trachea, in the breathing tube. So if I can get a lot of force on the lungs by pushing up on the stomach into the diaphragm, that's going to force that air out of the trachea, and hopefully make that piece of food pop right out.

Scot: So how hard am I doing this? Am I lifting somebody off the ground with each. . . what do you call that when you, each thing.

Dr. Madsen: Yeah so with each thrust there . . .

Scot: Thrust.

Dr. Madsen: You are lifting this person.
Scot: Okay.

Dr. Madsen: If you can you know, it's a lot of force.

Scot: All right.

Dr. Madsen: And again, you're thinking the more force the better. It's kind of like you know, you think about you're in grade school and you got like a . . . you're shooting spit wads at the ceiling or something. It's the same concept. It's just lots of air pressure all at once. Immediate force that shoots something straight up, and that's what you're trying to do with that force down there.

Scot: So how do you actually know if you should start administering the Heimlich maneuver to somebody?

Dr. Madsen: So this is a great question, because you know, the Heimlich maneuver is not without harm. There are plenty things that have shown you put that much force on a person's stomach, you can cause injury to their spleen, their liver, their large vessel, their stomach. So you really need to know this person is choking, and a universal sign of chocking is a person is holding their hands over their throat. Often times they may be turning blue. If a person can speak to you, that means they are moving air through their airway, they do not need the Heimlich maneuver, but that person generally, well they should not be able to speak because their airway is completely blocked, which means they can't get any air through there. You know, if they are speaking to you but feel like something's stuck in there you can call 9-1-1, but you don't need to start doing thrusts or forcing air into their lungs, or pushing on their stomach.

Scot: When we talked about CPR you tell your students that if you're not hearing ribs cracking, you're not doing compressions hard enough. Is there anything equivalent in the Heimlich maneuver?

Dr. Madsen: You don't want to crack ribs. You're going to be down lower there.

Scot: Okay.

Dr. Madsen: But I'm just . . . it's just got to be much force . . .

Scot: Much force.

Dr. Madsen: As you can push there. Yeah.

Scot: So channel any anger that you had towards . . .

Dr. Madsen: Yeah.

Scot: . . . relative right in there.

Dr. Madsen: Channel anger, fear, whatever emotions running through you at that point, channel it into those thrusts to really try and get some pressure there.

Scot: How long do I keep doing that?

Dr. Madsen: Keep doing it until they're responding.

Scot: Okay.

Dr. Madsen: And if they get to a point where they are unresponsive, where they lose a pulse, then you have to start CPR.

Scot: Okay.

Dr. Madsen: And often times, once you're doing in those chest compressions, those nice deep chest compressions, that sometimes will generate enough force on the lungs to make that food pop out. But you keep doing it until they respond.

Scot: What about the balance of somebody starts choking, somebody starts giving the Heimlich maneuver. Do you call 9-1-1 at that point? I mean at what point would you make that phone call?

Dr. Madsen: I would make it immediately. And if you're in a situation where you have other people there, that's one thing you're going to say, call 9-1-1. I'm doing the Heimlich maneuver. If I'm in a situation where it's just me and another person, I'm going to do the Heimlich maneuver.

Scot: Okay.

Dr. Madsen: But then if it gets to a point where you are administering CPR, then you call 9-1-1. But usually most of the time, if you just get the Heimlich maneuver going, you're going to be successful.

Scot: And then do you call 9-1-1 back and say cancel it or . . .

Dr. Madsen: I would still have them come.

Scot: Okay.

Dr. Madsen: And at the very least, the EMTs are going to come. They're going to evaluate the patient. In my experience, they will sometimes transport that patient to the emergency department, just depending if the patient still feels like something may be lodged in there. If the patient is completely symptom free, they may just release them. But at least you can get a medic to check their vital signs and check them out.

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Interviewer: When you watch your favorite TV show, you see somebody collapse and then somebody else comes to the rescue and administers CPR and they come back to life and everything's good. But is it really that effective in real life? With Dr. Troy Madsen, emergency physician at the University of Utah Medical Center. Does CPR work?

Dr. Madsen: I think the short answer to that question is yes. Does it work as well as we think it works based on TV shows? The answer there is no. Unfortunately, TV shows have kind of created an unrealistic expectation for us. I saw something that said when people perform CPR on TV shows or in movies, 75% of the time that person lives. That's not the case.

Interviewer: That's not real life.

Dr. Madsen: It doesn't happen that way, unfortunately. That number is probably closer to 5% realistically. A lot of it depends where the CPR occurs and who's doing it.

Interviewer: So, 5%, that doesn't sound very successful. Should people even bother to learn CPR?

Dr. Madsen: Well, those aren't great odds but it's all you can do. You figure the person's chance is 1 in 20 of surviving, but on the other hand you could save that person's life. So, absolutely I think it's worth doing and it's worth trying to see if you can make a difference.

Interviewer: So, even myself as a civilian who maybe took a CPR class two, three years ago, I don't exactly remember what I'm doing. Should I start pounding on the chest or not?

Dr. Madsen: Go for it. Jump in and do it.

Interviewer: Really?

Dr. Madsen: The wonderful thing about CPR that's come out in the last couple of years, maybe even since you had your last CPR class, is that they've made it really simple. Forget the breaths. Forget trying to blow in a person's mouth. I think people think about that; it just grosses them out. Just do chest compressions. And when you do them think of the song "Staying Alive." So, you think about that '70s disco song, it's 100 beats a minute and that's what you're going for. You're doing deep chest compressions, 100 beats a minute and just keep pushing on that person's chest until the ambulance gets there.

Interviewer: And just for a refresher course, you put your hands right on their heart? Is that where you're pressing?

Dr. Madsen: So, you're going to put it right over their sternum. So, if you feel on their chest, the hard bone . . .

Interviewer: More in the center.

Dr. Madsen: So, right in the center of the chest, exactly.

Interviewer: Okay.

Dr. Madsen: So, you're going to get right over the center of the chest, right over that really hard bone about halfway up and then get right over them with your fists down on the chest with your arms straight out and locked. Get your full force over them. We say to our medical students when you're doing CPR if you're cracking the person's ribs, you're doing the right thing.

Interviewer: Wow, really?

Dr. Madsen: Because you have to get that much force. You have to get down and really push on the heart. If you're breaking ribs, it's fine. Again the person's chances of living are 1in 20. We can easily treat broken ribs. You're saving their life potentially.

Interviewer: Absolutely.

Dr. Madsen: Another thing to keep in mind is you can get really tired doing CPR, you know. People tire out in maybe two minutes with those chest compressions, so if there are other people there, rotate out. Have people swap in. Keep the chest compressions going. Studies that have been done have shown that good chest compressions save lives. So, if you're doing the right thing, the right compressions, you could make a difference.

Interviewer: And how long should you keep that up before you just stop?

Dr. Madsen: Keep going until the ambulance gets there.

Interviewer: Gotcha.

Dr. Madsen: Once they get there they may find something that they could do quickly to potentially do something different. The big thing they're looking for is something where they can shock the heart. So, this is the other thing to keep in mind too. If you're in a place that has an AED, or an automated external defibrillator, like a school or a public building, get that. Put it on there. It's pretty much fool proof. It'll tell you if you can shock and if it says shock you push a button, it shocks the heart and that's the number one thing that can make a difference.

Interviewer: So, as I'm doing these chest compressions and I'm just going and going and going, am I looking for any signs of consciousness or am I just really doing the heart's job at that point, keeping the blood going around?

Dr. Madsen: So, as you're doing the chest compressions, you're going to take a very short break every minute or two, see if the person's breathing. You can just kind of lean over, you can feel for a pulse as well. And if it's not, you just keep going. So, that's the thing you're watching for, any sort of breathing, and any sort of a pulse. But in most of these situations, you're probably not going to get that, and hopefully in most situations you're going to have an ambulance there within five minutes.

Interviewer: If you're not getting that are you doing any good?

Dr. Madsen: You are. You are pushing blood to the body and to the brain.

Interviewer: So, you are. You are actually doing the heart's job at that point.

Dr. Madsen: Yeah. You are. You are doing the heart's job because you're pushing down, causing the heart to squeeze that blood out, and you're making a difference. And I can tell you I've had cases, certainly I've had many cases where we've done CPR and the person hasn't come back. But I've had cases where they have started CPR, person has been completely unresponsive, they've been out for 10, 15 minutes basically dead, doing chest compressions. We were able to shock the heart, get it back in rhythm. And the one case I'm thinking of in particular, the guy walked out of the hospital two days later, totally back to normal. Just absolutely remarkable. So, that can happen, and that's the reason you do CPR all these times is hopefully to have that one case where you save a life.

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